Overview
The complainant (Mrs C), an advocacy worker, raised a number of concerns on behalf of her client (Ms A) about Ms A's detention under the terms of a Short-Term Detention Certificate and her subsequent transfer, under nurse escort by ambulance, from the Royal Infirmary Edinburgh (Hospital 1) to the mental health unit at St John's Hospital (Hospital 2) in November 2011. Specifically, Mrs C complained about the way in which Ms A was transferred and that she did not receive appropriate information in relation to the detention and transfer.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) Ms A was forcibly transferred from Hospital 1 to Hospital 2 without any prior knowledge or explanation of reasons (upheld);
- (b) Ms A was inappropriately told she was being detained under the Mental Health Act but has no recollection of being detained (upheld); and
- (c) the manner in which Ms A was wrapped in a blanket and strapped to a trolley, causing severe bruising to her shoulders, was unreasonable (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) ensure that where detention and/or transfer is being considered, the matter is fully discussed with the patient and they are informed of the options available to them and the rationale underpinning the decision;
- (ii) ensure that in such cases discussions in relation to the patient's care and treatment and actions taken, including the use of medication, are clearly recorded in the clinical notes;
- (iii) ensure that, where restraint is required during the transfer of a patient, the appropriate incident report is completed in line with Board policy and the event clearly recorded in the clinical notes;
- (iv) feed back the learning from this complaint to all relevant staff in both hospitals;
- (v) ensure that all staff involved in taking decisions on short term and emergency detention are aware of the requirements of the Mental Health legislation and adhere to the appropriate process when carrying out any detention; and
- (vi) ensure that a physical examination is conducted on a patient on their arrival at a hospital, especially if the patient was the subject of a physical restraint en-route to the hospital; and
The Ombudsman recommends that:
- (i) this report be considered at a meeting of the Lothian NHS Board.
The Board have accepted the recommendations and will act on them accordingly.